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You’re going to get a Pap smear from where?! Explaining the anal Pap smear

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Carolyn came to my office as a new patient. She was 26 years old, and because she had a kidney transplantation a couple of years ago, she was on medications to suppress her immune system to help her body accept her transplanted kidney. She felt well overall, but was worried because her Pap smear last year showed human papillomavirus (HPV) infection. She requested a repeat Pap smear, also called a Pap test.

I suggested regular Pap tests and HPV testing, along with anal Pap tests and HPV testing. Carolyn understandably replied, “You’re getting a Pap smear from where? Why?”

I understood her reservation and tried to explain more. Most adult women are familiar with the standard vaginal Pap test, which collects cells from the cervix as a screening for cervical cancer. This can be done with or without testing for HPV. Anal Pap tests and HPV testing are done to detect anal cancer.

Men who have sex with men and are HIV-positive have the highest rates of anal cancer. While anal cancer is rare in healthy heterosexual men and women, it is steadily increasing in the last decade, especially in women in the Western hemisphere. Certain medical conditions increase your risk of developing anal cancer, such as HIV infection, organ transplant, immune-suppressing medications, and a prior history of vulvar, vaginal or cervical cancer.

Carolyn asked what signs and symptoms come with anal cancer. Usually, people have rectal bleeding and pain. Unfortunately, many times these symptoms can be mistaken for hemorrhoids, so people neglect to get them checked out.

She also wanted to know why she needed two HPV tests — one with the standard vaginal Pap from her cervix and one for the anal Pap.

This is because you can have an HPV infection in your vagina, anus or both — due to the anatomical proximity of the anal and genital areas, women can simultaneously get vaginal and anal HPV infections. HPV is now the most common sexually transmitted infection (STI) in the United States. In fact, 91% of anal cancers and 99% of cervical cancers are caused by HPV infection.

Carolyn was then convinced; she was not experiencing any symptoms, but she realized she needed this test as she was at higher risk of anal cancer due to her immune-suppressing medications and previous positive HPV test. She consented to an anal Pap test with HPV testing.

To prepare for the procedure, Carolyn was instructed to avoid anal intercourse, enemas and douching for at least 24 hours before testing.

For the actual procedure, I first collected her vaginal Pap and HPV with her feet in stirrups. Afterward, she lay on her left side to allow the anus to be fully exposed and visible.  A special polyester swab moistened with water was inserted about 1.5 to 2 inches (3 to 5 centimeters) into the anus and rotated gently to collect the specimen. This whole procedure took less than five minutes to complete.

Carolyn reported no pain or discomfort and got dressed. She wondered what would happen if the test came back abnormal.

Most healthy men and women with an intact immune system clear the HPV infection within one or two years. People who do not clear the infection or show irregular cells on the Pap smear are referred to colorectal surgeons who specialize in performing a procedure called high-resolution anoscopy, where a small magnifying device is passed into the anus to allow for a more detailed and careful exam.

Our last topic of the day was the HPV vaccine. Vaccination protects against getting high risk strains of HPV virus, which can cause several cancers such as anal, cervical, vaginal, vulvar and oral cancers. Since Carolyn had not been previously vaccinated, we started the three-dose HPV vaccine series that day. The Centers for Disease Control and Prevention recommends HPV vaccination for all people age 26 and younger; vaccination may be recommended for people age 45 and under who are at higher risk of HPV infection.

Suneela Vegunta, M.D.

Dr. Vegunta is a board certified Internist, practicing as a women’s health consultant at the Mayo Clinic in Arizona. Her interests include menopause, sexual health and breast health. She also teaches at the Alix School of Medicine at Mayo Clinic, AZ.

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